Westbury Medical Centre

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

We looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture

At our last assessment, we rated this key question as good. At this assessment, the rating has changed to requires improvement.

The service was in breach of legal regulation in relation to good governance

This service scored 50 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service did not have documentation around a mission/vision statement or around strategy, transparency, equity, equality and human rights, diversity and inclusion. The staff had not had specific discussions covering this area. However, our observations showed staff were patient focused and put importance on meeting their needs. We observed the staff and management worked well with each other and with their patients.

Leaders did not always understand the context in which the service delivered care, treatment and support, Leaders and staff were focussed on patient care. However, this was not always supported by effective systems and fundamental practices including cleanliness, infection control and storing chemicals, medicines and paperwork.
Staff told us leaders in the practice were approachable and responded to any concerns raised. The practice worked with other practices in their primary care network and were engaged in the development of primary care services within the local area.
 

The practice did not have established Freedom to Speak up arrangements in place. A poster was displayed in the practice about Freedom to speak up, however staff did not have a clear understanding of the arrangements or how to raise concerns.

The service valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

Policies and procedures to promote diversity and equality were not readily available.

The service did not have clear responsibilities, roles, systems of accountability and effective governance. They did not act on the best information about risk, performance and outcomes.

Governance processes were not effective or established into practice in identifying or addressing risk or areas for improvement in addition to general record keeping. Staff had access to a limited range of policies and procedures; however, these were not always service specific, consistently adhered to or regularly reviewed to inform practice, where there were policies in place staff were often unaware of them or their content. In April 2026, the provider sent us a range of policies provided by their Primary Care Network, which they had agreed and signed up to and had made them service specific.

The practice did not have systems in place to ensure effective governance, oversight and accountability for medicines safety, health and safety or staff recruitment and training. Records requested by CQC were not made available in advance of or on the day of the site visit to support good governance. Following the site visit some records were later shared with us.

Leaders and managers supported staff and met with them to complete meetings and appraisals. However, not all staff we spoke with were clear on their individual roles and responsibilities and records of meetings held were not available during our site visit and therefore not readily accessible to all staff. Staff did not always take patient confidentiality and information security seriously. Patient paper records were not stored securely to prevent unauthorised access and a risk assessment had not been completed to mitigate the risk of breaches to patient confidentiality.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. The practice was part of the Shropshire Rural Alliance Primary Care Network (PCN) comprising of 5 GP practices serving approximately 30,000 patients in and around rural Shropshire. The PCN were an integrated community-based team delivering a range of additional services such as extended hours, paramedic home visiting and first contact physiotherapists. Staff had made adjustments to improve coordination of their service with community healthcare services.

The practice did not have an active patient participation group (PPG) to represent the voice of people using the service to help improve service delivery.

Following our site visit, the local Integrated Care Board (ICB) visited the practice and offered support to leaders and helped with the development of an action plan to address the actions detailed in the CQC warning notices we served. The ICB told us they were providing ongoing support to the practice and weekly meetings were being held with them.

The service did not have a focus on continuous learning and improvement across the organisation and local systems.

The practice did not have a documented quality improvement plan in place to drive improvements. However, they shared future staffing plans with us including potential partnership changes in addition to the possibility of recruiting a mental health trained nurse to enhance the team.

The lead GP told us they were the clinical cancer lead for the Integrated Care Board (ICB) and had previously been the Senior community paediatrician in Shropshire.

The practice shared a limited number of audits they had undertaken to measure and improve the quality of clinical care and patient outcomes.